[Reconstruction of proximal nasal defect after deep carcinological resection. Interest to combine titane mesh with fat grafting]. / Reconstruction de la racine du nez après exérèse carcinologique profonde. Intérêt de combiner implants de titane et greffe de tissu graisseux.

INTRODUCTION: The mucosal cylindroma or adenoid cystic carcinoma is the second sinonasal non-epithelial malignant tumor frequency argument. Due to the achievement of the nasal mucosa and a late diagnosis reconstructions are often complex. We report the case of a mucous cylindroma recurrence of nasal septum requiring a wide and deep excision of the root of the nose with nasal reconstruction. CASE REPORT: A patient aged 66 years whose history resection two years ago with a mucous adenoid cystic carcinoma of the right side of the nasal septum, had a local recurrence T2NOM0 imposing a wide excision with amputation nasal septum own bones of nose, the anterior portion of the triangular cartilages. The reconstruction was carried out in three areas: a musculocutaneous forehead flap to the mucosal level, a titanium plate to the bone plane, nasal native skin to skin level. Histological examination confirmed the existence of a recurrence cylindroma infiltrating the bone. The surgical margins were however in sano. Adjuvant radiotherapy to 60Gy dose of the surgical area was indicated after surgery. The consequences of surgery and radiotherapy were simple. However local changes to show a progressive refinement of the nasal skin due to irradiation leading to a small titanium plate exposure revision surgery with coverage by a glabellar flap associated with a time of lipomodeling unexposed areas have improved and trophism of soft tissue. Two further lipomodeling sessions have yielded a good quality and stable skin. From an oncological point of view, no recurrence was detected with a decline of 10 years. Aesthetic and functional point of view the results were highly satisfactory. DISCUSSION: Oncologic resections subtotal nasal pyramid are complex, we will see the benefits and disadvantages of the different techniques used in the different stages. CONCLUSION: This case report illustrates the difficulties of reconstruction after wide excision of mucosal lesions root of the nose carrying the mucous plan and nasal bones. It stresses the importance of bone reconstruction titanium plate and innovative element, the efficiency of fat transfer to restore the quality and trophicity soft tissue. Fat transfer in addition to reconstructions by titanium plates and splints may thus expand the indications of these types of techniques in complex facial and cranial reconstructions.

Breast reconstruction with fat grafting and BRAVA(®) pre-expansion: Efficacy evaluation in 45 cases.

INTRODUCTION: Fat grafting for breast surgery, in reconstruction or aesthetics, gained a lot of popularity over the last years. As an addition to breast reconstruction with flaps or prosthesis, lipofilling improved the aesthetic result, increasing the patients' satisfaction rate. The demand for breast reconstruction using only fat grafting increased, because patients want a natural result in breast reconstruction and also the body contouring associated with liposuction of specified fat areas. The pre-expansion BRAVA(®) system has been used for several years in the United States to prepare the receiving site for lipofilling. We wanted to gain our own experience in associating BRAVA-lipofilling in breast reconstruction. The aim of our study is to evaluate the BRAVA efficiency as an adjuvant for fat grafting in breast surgery. MATERIAL AND METHODS: A retrospective study was undertaken, using a homogenous series of consecutive patients, operated by one surgeon (the first author), that had breast reconstruction using only fat grafts associated with BRAVA(®). RESULTS: The retrospective homogenous study identified 45 cases of breast surgery associating fat grafting alone with BRAVA(®) assistance. The number of intervention of fat grafting associating BRAVA(®) was 1 or 2 for conservative treatment sequelae or for flap reconstruction improvement, and 2 to 4 for immediate and delayed breast reconstruction. The total volume of fat grafting was 205 cc for the contralateral balancing, 317 cc for flap reconstructions, 531 cc for the conservative treatment sequelae, 790 cc for the immediate breast reconstruction and 1165 cc for the delayed breast reconstruction. The satisfaction rate of the surgical team and the patients was satisfying and very satisfied in 82% of cases, average in 8% of cases, and insufficient in 10% of cases. CONCLUSIONS: Breast reconstruction with fat grafting alone is, in our experience, a reliable and reproducible technique, that gives excellent and stable results. The high satisfaction rate of patients is explained by the supple and natural consistency of the new breast, with no added scars, associating the benefits of liposuction of the donor sites. The BRAVA(®) system seems to be, in cases with good indications, an adjuvant for receiving site preparation, making the reconstruction easier for the surgeon and for the patient. We believe that breast reconstruction with fat grafting alone is going to become more popular in the future. Associating fat grafting with BRAVA(®) creates a new way of natural breast reconstruction for the patients with mastectomy that want a stable result with less aggressive procedures. It is a new tool that is going to increase the autologous breast reconstruction in France.

[How to treat fat necrosis after lipofilling into the breast?]. / Comment gérer les lésions de cytostéatonécrose mammaire après transfert graisseux ?

INTRODUCTION: Fat necrosis is a phenomenon that has been known for a long time in surgery. The fat necrosis is produced because of tissue ischemia and it is also known as cytosteatonecrosis. These lesions can appear with different manifestations: indurations or cysts. Fat necrosis develops in breast aesthetic surgery (breast reduction) or reconstructive breast surgery (after abdominal flaps like TRAM or DIEP). In our department we have been using fat grafting into the breast since 1998 and it has really improved the aesthetic results in breast surgery. Also the fat necrosis lesions can appear after fat grafting, and they should be identified in order to avoid worrying the patient and other doctors that are treating her. The purpose of this article is to present different aspects of fat necrosis after surgery and therapeutic approaches to these problems. MATERIAL AND METHODS: The two authors have noticed the frequency of fat necrosis in the breast after fat grafting into the breast in aesthetic surgery (asymmetry, deformity, lipoaugmentation, improvement of aesthetic sequelae) and reconstructive surgery (after total mastectomy or to improve the aspect of sequelae after conservative surgery). A retrospective study was performed including a homogenous series of consecutive cases that needed breast lipofilling, operated by the two authors. Fat was harvested with cannula after infiltration. The adipose tissue was preparated with a short centrifugation. Fat grafting was realized as backward injections. The tolerance of the performed technique has been studied with the discovery of the fat necrosis lesions after surgery up to one-year follow-up evaluation. RESULTS: Between 1998 and 2013, 2236 fat transfers have been performed by the two authors and were included in a series of consecutive homogenous cases treated by using the same surgical technique. The fat necrosis incidence after lipofilling in the breast shows two frequency curves: the first one with a frequency of 15% (the first 50 cases) and then decreases and stabilizes at about 3%. A second frequency curve appears after 500 cases and fat necrosis has a frequency of 10%. The clinical symptoms are variable. The oil cysts are the most frequent and the earliest manifestation. They can be treated in consultation by punction. The cysts with thick yellow filling and the indurate areas of fat necrosis are rare and can be treated by lipofragmentation using a canula. CONCLUSIONS: The fat necrosis lesion is a classic phenomena, and can be a source of inconveniences for the patients and the surgeons after breast surgery. All the efforts should be directed to avoid fat necrosis. However, fat necrosis is not rare and the surgeon should learn to resolve it without worrying the patient or asking for expensive exams.

Volumetric evaluation of fat resorption after breast lipofilling.

INTRODUCTION: The fat transfer or the lipofilling is a technique that had a major impact on the breast surgery results. We have been using this technique since 1998 as an adjuvant in breast reconstruction. The transferred fat is partially resorbed in the first three months after fat grafting. Literature shows that fat resorption varies from 30 to 80% and the experimental studies register a variation between 50 and 90%. The difficulty of the lipomodeling consists in anticipating the fat resorption rate in order to obtain breast symmetry. The purpose of this article is to evaluate the resorption rate of the transferred fat in the reconstructed breast by means of volumetric imaging 3 months after fat grafting. MATERIAL AND METHODS: A prospective study was undertaken including breast reconstructions with total autologous latissimus dorsi. All the surgical procedures have been done by the same surgeon (1st author). It focused on the second stage of breast reconstruction: the lipofilling. We registered the average harvested volumes, the volumes obtained after centrifugation and the transferred volumes for every reconstructed breast. The intramuscular volume in the reconstructed breast was measured by volumetric imaging on the third day after lipofilling (D3) and three months after lipofilling (M3). The volumetry was performed by using an after treatment console SIEMENS (SOMATOM definition AS 2*64 barettes). The average intramuscular volume was registered at D3 and M3. The average volume difference was calculated in order to obtain the exact resorption rate. RESULTS: This prospective study was undertaken on 32 reconstructed breasts by total autologous latissimus dorsi flap. The average age was 52 years, the average BMI was 24.7 kg/m(2). The average harvested fat volume for the breast lipofilling was 560 cc and the volume obtained after centrifugation was evaluated at about 371 cc, the average fat volume transferred being 291 cc. The volumetric study showed that intramuscular volume at D3 was measured at 284 cc and at M3 about 223 cc, of a resorption intramuscular rate of 21.5%. CONCLUSION: In our study, the rate of resorption of the fat transferred to the muscle in the reconstructed breast was measured at 21.5%. The low resorption rate found in our study, lower than those in the literature, sustains the supposition that the muscle is an excellent receiving matrix for the fat tissue. In order to obtain this percentage, a learning curve is necessary. Once acquired, this technique produces a major improvement of the breast surgery results.

[Dynamic reconstruction of Achilles tendon by free composite perforator flap with functional assessment]. / Reconstruction dynamique de tendon d'Achille par lambeau perforant composite avec évaluation fonctionnelle.

INTRODUCTION, DEFECTS: Achilles tendon are common in patients after immobilization, therefore the reconstruction of a ruptured Achilles tendon with defects remains a surgical challenge. The ideal characteristics are a thin layer of skin, a strong tendon component, combined with a reliable blood supply and minimal morbidity at the donor site. We present a reconstructive technique using a composite anterolateral thigh perforator free flap, meeting these criteria, for the treatment of rupture of Achilles tendon with cutaneous and tendon defect. METHODS: A 34-year-old patient presenting a third rupture of his left Achilles tendon with 4cm composite defect was reconstructed with a contralateral anterolateral thigh perforator flap with part of the fasciae latae. The latter was raised by dissecting one intramuscular perforating artery from a descending branch of the lateral circumflex femoral artery. The postoperative observation period was one year. The functional outcome was determined by clinical scores (IKDC, OAK and Lysholm-Tegner). RESULTS: The healing time was 21 days. At six months, the aesthetic and functional result was satisfactory without delayed healing or secondary rupture. The aesthetic discomfort at the donor site was considered negligible by the patient. At one year, there is a continuing stability with no recurrence. The functional result was considered good with a clinical score of 75/100. CONCLUSION: Therefore, this method seems to be a good option for complex reconstruction of Achilles meeting the requirements of reconstruction with good stability at a distance.

[Long-term outcome of lipomodeling in Poland's syndrome: about our first case with an eleven-years' follow-up]. / Évolution de la reconstruction mammaire par lipomodelage dans le syndrome de Poland: à propos d'un cas avec un recul de onze ans.

Poland's syndrome is a rare congenital malformation with thoracic and breast deformities very difficult to treat. Several techniques can be used involving, sometimes, implant insertion. Most of the classic techniques could not be used in this patient. Particularly, the transfer of the latissimus dorsi flap could not be performed because of the agenesis of the muscle. Lipomodeling is used, in our team, for breast reconstruction since 1998. This case was described and published one year after the end of the reconstruction in 2004. The immediate outcome appeared very satisfying and effective but some surgeons remained skeptical. An important question remains: what about the long-term efficiency and stability of the reconstruction? In this review, we report our first case of severe Poland's syndrome treated eleven years ago with lipomodeling. The patient was twelve years old. She had a severe form of Poland's syndrome. Five fat grafting sessions were performed between 2001 and 2003, for a total transfer of 809 ml. Today, outcome is very satisfying with a natural breast shape, consistency and sensitivity. An increase of volume in the reconstructed breast is noted. It is due to a rapid and significant weight gain by the patient. We performed two shorts movies describing this outcome one year and ten years after the reconstruction. It confirms the stability and the sustainability of the reconstruction. Lipomodeling does not interfere with breast ultrasound surveillance. Fat grafting deeply improved outcomes and management of thoracic and breast deformities in Poland's syndrome.

Lipofilling, an efficient solution for breast sequelae after cardiothoracic surgery.

Evolutions in pediatric cardiovascular surgery have allowed the treatment of a various range of cardiovascular malformations in infants. It is a difficult branch of surgery, with vital impact, which can also leave residual thoracic scars, possible sources for thoracomammary deformities in adults. Most thoracomammary deformities after thoracotomy are observed at puberty, when they appear as breast asymmetries. The main cause is the breast bud injured during thoracotomy. Several techniques have been suggested for breast reconstruction, but none give satisfying results. We have been practicing lipofilling since 1998 for breast reconstruction. Since 2001, we have started applying it to breast deformities. The final result is constant in time, natural, and has a good volume filler effect. We describe the fat grafting technique, an original technique, as a solution for this kind of deformities. The technique is illustrated by two clinical cases. In conclusion, fat grafting has really improved breast asymmetry due to iatrogenic deformation. Even if those cases are rare, surgeons have to know this kind of procedure. It is indeed a simple and efficient solution for those patients after childhood, with natural and long standing results.

Breast lipofilling: A new treatment of Becker nevus syndrome.

INTRODUCTION: The association of Becker's nevus with other cutaneous, musculoskeletal or maxillofacial anomalies is called Becker nevus syndrome. Ipsilateral breast hypoplasia is the main reason for female patients to seek medical advice. We present two clinical cases of Becker nevus syndrome with thoracic nevus and ipsilateral breast hypoplasia treated with lipofilling alone (fat grafting). MATERIAL AND METHODS: For the two consecutive cases of Becker nevus syndrome treated by fat grafts, we present the surgical technique and the outcome at one year follow-up. Fat was harvested with cannula after infiltration. The adipose tissue was prepared with a short centrifugation. Fat grafting was realized as backward injections. RESULTS: We have noticed a concomitant improvement of the thoracic nevus color with a stable result after one-year follow-up. The aesthetic result after lipofilling was evaluated as very satisfying by the patient. The breast symmetry was improved. CONCLUSIONS: We believe that the lipofilling technique is a natural and valuable treatment option for thoracic anomalies in Becker nevus syndrome with a major impact on patient's quality of life.

[Tolerance of latissimus dorsi without implant to radiotherapy in immediate breast reconstruction]. / Tolérance du lambeau de grand dorsal sans prothèse à la radiothérapie en reconstruction mammaire immédiate.

OBJECTIVES: Rates of immediate breast reconstruction (IBR) after mastectomy are currently increasing, leading us to evaluate outcomes of breast reconstruction with latissimus dorsi without implant followed by adjuvant radiotherapy. MATERIALS AND METHODS: From January 1999 to August 2013, 31 breast reconstructions with latissimus dorsi have been irradiated. Patients have been selected from a prospective database and contacted to evaluate outcomes of breast reconstruction, and 2 patients have been lost. RESULTS: Median follow-up was 6.5 years. Breast reconstruction outcomes were evaluated as very good or good in 86% of cases, with breast reconstructed consistency as very good or good in 93% of cases. An additional fat grafting has been performed for 58% of cases (mean volume transferred of 250 cc) and was associated with contralateral breast reduction in 32% of the whole population. IBR was judged as essential for 79% of women a posteriori. CONCLUSION: In our experience, latissimus dorsi has a good tolerance to adjuvant irradiation, and may be offered to patients willing to benefit of an IBR even if postoperative radiotherapy is scheduled.

[Tolerance and efficacy of lipomodelling as an element of breast symmetry in breast reconstruction]. / Tolérance et efficacité du lipomodelage comme élément de symétrisation en reconstruction mammaire: à propos de 150 patientes.

AIM OF THE STUDY: Fat transfer significantly improved results in breast reconstruction. Final breast symmetry is very important in breast reconstruction, but sometimes, the result is not perfect with usual techniques. The aim of this study is to evaluate the tolerance and efficacy of lipomodelling as a complementary technique for breast symmetrisation. MEANS AND METHODS: In this study, 150 patients had controlateral breast symmetrisation after breast reconstruction, using or completed with fat transfer. Patients were clinically evaluated one year after surgery. Age, BMI, harvested, purified and transferred fat volumes, and postoperatory complications were recorded. Morphological outcomes were evaluated by the surgeon as: very good, good, average or bad. Patients rated their degree of satisfaction as: very satisfying, satisfying, poor or bad. RESULTS: We found out that 98.6 % of morphological results were good or very good, and 86.6 % of the patients were satisfied or very satisfied with the result. Complications were rare (2 % of cytosteatonecrotic lesions). CONCLUSION: Lipomodelling in native breast symmetrisation after reconstruction is a powerful technique because it allows to increase volume of a hypoplastic controlateral breast, to ameliorate its shape, and to finally enhance mammoplasty result by correcting persisting localized volume defects. It definitively is a major therapeutic tool for enhancing breast reconstruction outcomes.

Preoperative imaging prior to breast reconstruction surgery: benchmarking bringing together radiologists and plastic surgeons. Proposed guidelines.

BACKGROUND: Prescription of preoperatory imaging assessment prior to planned breast reconstruction surgery (reduction or augmentation mastoplasty, correction of congenital breast asymmetry) is poorly codified. The objective of this study was to analyze the attitudes of French radiologists and plastic surgeons with regard to prescription of preoperative imaging in the framework of non-oncologic breast surgery. MATERIAL AND METHODS: This is a descriptive and comparative observational study involving two groups, one consisting of 50 plastic surgeons (P) and the other of 50 radiologists (R) specialized in breast imaging. A questionnaire was handed out to radiologists during a conference on breast imaging at the Institut Gustave-Roussy in Paris (France) held on 17th December 2012. The same questionnaire was handed out to plastic surgeons at the National Congress of the French Society of Plastic and Reconstructive Surgery (SOFCPRE) held on 19th, 20th and 21st November 2012, also in Paris (France). The questionnaire focused on prescription of preoperative and postoperative imaging evaluation for non-oncologic breast surgery in patients with no risk factors for breast cancer or clinically identified indications. RESULTS: Forty-six percent of the plastic surgeons considered an imaging exam to be recent when it had been carried out over the previous 6 months, while 40% of the radiologists set the figure at 1 year. Clinical breast density exerted no influence on 92% of the plastic surgeons and 98% of the radiologists. A majority of the plastic surgeons would prescribe a preoperative exam regardless of age (57% for breast reduction, 61% for breast implant placement and 61% for surgical correction of asymmetry) while the radiologists would prescribe exams mainly for patients over 40 years (50% for reduction, 44% for augmentation, 49% for asymmetry correction). The plastic surgeons would prescribe either ultrasound or mammograms (59% for reduction, 72% for augmentation, 66% for asymmetry correction) while radiologists would usually prescribe mammograms (64%, 57%, 64%). Most of the radiologists, along with the plastic surgeons, did not think that postoperative examination is justified (58% of P and 62% of R for reduction, 56% P and 68% of R for augmentation, 52% of P and 64% of R for asymmetry correction). CONCLUSION: In 2012, there existed no French consensus on prescription of a preoperative imaging assessment in the framework of non-oncologic breast surgery in patients without risk factors for breast cancer. Active cooperation bringing together radiologists and plastic surgeons is likely to facilitate the harmonizing of their respective practices. In this paper, we propose guidelines that could help them to synchronize their efforts.

Reconstruction of cubital fossa skin necrosis with radial collateral artery perforator-based propeller flap (RCAP).

In recent years, perforator flaps have become an indispensable tool for the reconstruction process. Most recently, "propeller" perforator flaps allow each perforator vessels to become a flap donor site. Once the perforator of interest is identified by acoustic Doppler, the cutaneous or fascio-cutaneous island is designed and then customized according to the principle of "perforasome". So, the flap can be rotated such a propeller, up to 180°. Ideally the donor site is self-closing, otherwise it can be grafted at the same time. Through a skin necrosis secondary to a contrast medium extravasation of the cubital fossa in a 47-year-old man, we describe the use of propeller perforator flap based on a perforator of the radial collateral artery (RCAP). The perforator was identified preoperatively by acoustic Doppler then the flap was adapted bespoke to cover the loss of substance. Ultimately, the result was very satisfying. Well experienced for lower-extremity reconstruction, perforator-based propeller flap are still few reported for upper limb. It is likely that in the future, propeller flap supersede in many indication not only free flaps and locoregional flaps but also, leaving no room for uncertainties of the vascular network, the classic random flaps.

[Percutaneous fasciotomies to improve fat grafting into the breast]. / Fasciotomies percutanées en complément des transferts graisseux: indications en chirurgie du sein.

INTRODUCTION: Breast reconstruction or for breast deformities is a difficult challenge to get excellent results. Lipomodeling technique can improve thoracic malformations and breast deformities. Percutaneous fasciotomies can be an excellent tool for recipient site improvement. The aim of this study is to discuss interest of percutaneous needle fasciotomies with fat grafting into breast surgery. MATERIAL AND METHODS: We have realized a retrospective study with fat transfer into the breast surgery. Recipient site prepared fasciotomies during fat grafting surgical procedure. Fat was harvested and centrifugated. Fat was injected into breast reconstructions or thoracic malformations. We did notice: population (age, BMI, uni/bilateral breasts), surgical procedure (mean sessions number, mean fat transfer). Aesthetic aspects of breasts were rated by both surgeon and patient: skin improvement, volume and shape of breast. Each complication was noticed: tissue wounds, scar evolution, hematoma, infection. RESULTS: We started a retrospective study between 2006 and 2011. One thousand patients were treated with fasciotomies and fat grafting during the same procedure. Main indications were breast reconstruction with latissimus dorsi flap, breast implant reconstruction, breast cancer conservative surgeries, tuberous breast and Poland syndrom. Sessions number expected was between 1 and 3. No complication has been noticed, except 1 tissular wound that needed a medical treatment to solve the problem. CONCLUSION: Fasciotomie is an indispensable complement tool for fat grafting. It is a safe and reliable technique. It improves aesthetic outcomes of breast surgery. Main indications of fasciotomies with fat grafting are breast reconstruction with radiation, breast cancer conservative surgery, and tuberous breast. Percutaneous fasciotomies provide excellent aesthetic result with no scar. They improve the shape of the breast with long-standing result.

Lipomodelling: an important advance in breast surgery.

Based on long-term experiences, the authors consider lipomodelling to be a major advance in plastic, reconstructive and aesthetic surgery of the breast. The technique is now well established and the complication rate is very low. The risk of focal fat necrosis is around 3%. Oncological follow-up (now 14 years for the first patients) shows no increased risk of local recurrence or development of a new cancer. 30-40% of the injected fat is absorbed. Volume of the breast becomes stable in 3 to 4 months and remains definitive if the patient maintains constant weight. Because of very good results obtained and excellent acceptance of the procedure by the patients, this technique has completely modified our indications. In breast reconstruction, lipomodelling with autologous latissimus dorsi flap enables obtaining an entirely autologous breast in the majority of the patients. Analogically, lipomodelling can improve results of implant reconstructions, especially if the expander or the implant is planned to be exchanged. Lipomodelling is an effective tool for correction deformities especially in the décolleté after breast reconstruction with abdominal flap (DIEP, SIEA and TRAM). Lipomodelling is also progressively used in the correction of breast and chest wall deformities. In Poland syndrome, this technique appears to be a major advance that will probably revolutionize the treatment of severe cases. This is mainly due to its ability to achieve previously unachievable quality of reconstruction with minimal scaring. The application of lipomodelling in the treatment of pectus excavatum deformities is promising. Lipomodelling represents an advanced therapeutic alternative for tuberous breasts without the need to use an implant, as well as for breast asymmetry due to unilateral hypoplasia. Lipomodelling is an ideal option for cosmetic breast augmentation in patients who wish to achieve moderate, natural enlargement of breasts and who have considerable fat deposits.

[Tolerance of pre-expansion BRAVA and fat grafting into the breast]. / Tolérance de la pré-expansion BRAVA en complément des transferts graisseux dans le sein.

INTRODUCTION: Fat grafting is very interesting for breast reconstruction and for breast deformities. Fat grafting can improve results with a long-standing follow-up. Pre-expansion with BRAVA® can be a powerful tool for recipient site improvement. The aim of this study is to evaluate tolerance of BRAVA by the patient. MATERIAL AND METHODS: We do realize a prospective study with fat grafting into the breast surgery. Recipient site was prepared with BRAVA®: 4 weeks before surgical procedure, and 2 weeks after surgical procedure. Fat was harvested, centrifugated, and injected into breast reconstructions or breast augmentation. Following items were noticed by the patient after they wear BRAVA: pain, noise, sleep, infection, skin redness, motivation, skin bubbles. We have noticed if the patient has stopped BRAVA. RESULTS: Twenty-three breasts were treated with BRAVA and fat grafting. Main indications were four mastectomies with radiation, five mastectomies without radiation, three breast cancer conservative surgeries, six breast reconstructions with flap improvements, one breast implant reconstruction failure, one deformity due to a surgical cardiac procedure and three contralateral breast augmentations. Only twenty-one patients succeed to wear BRAVA during one cycle. We have noticed no pain, no motivation loss, no infection. We have noticed 86% of skin redness, and 9,5% sleep troubles and noise troubles. No patient had stop BRAVA during the cycle. CONCLUSION: Tolerance of BRAVA is very good for the patient. Main troubles are skin redness. We have noticed any infection, any pain and any motivation loss. If patient can understand how to wear BRAVA, it's important to explain every item of complications. It's a reliable and safe pre-expansion. Another prospective study would evaluate efficiency of BRAVA with fat grafting versus fat grafting alone.

[Esthetic gluteal remodeling by fat grafting]. / Remodelage fessier esthétique par transfert graisseux.

INTRODUCTION: The most common surgical techniques performed for gluteal augmentation employ gluteal implants. Gluteal augmentation is today a consultation request for many patients. The results can be interesting, but this surgical procedure can provide some complications. Fat grafting is reliable technique to remodel the buttocks. The aim of this study is to describe our experience for buttocks remodeling with fat grafting. METHODS AND TECHNIQUE: A prospective study has been performed, including patients that have been operated for buttocks remodeling with fat grafting in our department during one year. We have recorded the average age and body mass index of each patient, the total volume transferred for each patient, and the postoperator complications (infection, hemorrhage, seroma, fat embolism). The end result was evaluated by the patient and the surgical team using four criteria: very satisfying, satisfying, fair and poor. RESULTS: A prospective study including 24 cases of buttocks remodeling corrected with fat grafting. The average age was 43 years (30 to 65 years) and the average body mass index was 20.4 (18 to 24,2). The average volume transferred for each patient was 280cm(3) (from 140 to 440cm(3)). The patients and the surgical team were very satisfied or satisfied in 87,5% of cases. In this series we had no complications (infection, hemorrhage, fat embolism). We only had one seroma. CONCLUSION: Fat grafting is a reliable technique, simple and safe procedure. Fat grafting is an excellent indication for moderate buttocks remodeling. Surgery for correction of the buttocks may involve more than projection and volume. However, these must be in a balanced proportion with the rest of the body.

[Transtibial amputation salvage with a cutaneous flap based on posterior tibial perforators]. / Sauvetage d'un moignon d'amputation transtibiale grâce à un lambeau cutané basé sur les perforantes de l'artère tibiale postérieure.

When performing an amputation of the lower limb, the preservation of the knee joint is important to obtain an optimal functional outcome. Many reconstruction procedures are available to cover the amputation defect in order to preserve a sufficient length of the stump, so a prosthesis could be put in place with the best functional results. Local musculocutaneous flaps or free flaps are conventionally described with their advantages and disadvantages. In this report, we describe our experience with a transtibial amputation and stump covering using a fasciocutaneous flap based on tibial posterior perforators. An extensive tibial bone exposure with only posterior skin was viable. It is an efficient and reliable solution for covering tibial stump without microvascular anastomosis.

[Treatment of Poland syndrome thorax deformity with the lipomodeling technique: about ten cases]. / Correction de la déformation thoraco-mammaire du syndrome de Poland par la technique du lipomodelage : à propos de dix cas.

The correct management, with the classic techniques, of the thoracic deformity in Poland's syndrome is difficult, with often insatisfactory results. The current surgical treatment involves the use of prothetic material and/or different flaps with their own complications and scares. The experience of our team with fat grafting (we named lipomodeling) in breast reconstruction helped us to propose the correction of the thoracic and mammary deformity by repeated fat transfer sessions. Fat grafting is commonly used in our team since 1998 in various indication of breast surgery. We reviewed retrospectively our ten first cases of thoracic deformity in Poland's syndrome treated with only fat grafting. Patients had repeated procedures until obtaining a satisfactory result. The fat was harvested from the thigh, buttocks, and abdomen. There were young patients with a mean age of 16years old (from 12 to 24). The mean follow-up was 51months. An average of 2.9 procedures (1 to 5) with 255cm(3) of fat injection at each procedure was needed to obtain symetry. Hundred percent of the patients were satisfied. No complication was noted. As reported, the reconstruction of the thoracic deformity and the mammary shape can be obtained by fat grafting. The absence of a flap donor site sequelae and the absence an implant allow this technique to be simple, reproductible, and without great complication. These criteria match well the surgical management of this deformity, which is mainly aesthetic. Moreover, the secondary benefit of liposuction of disgracious steatomery helps the acceptance of the procedure. Therefore in our hands, fat grafting to the breast (lipomodeling) is now our first choice treatment in thoracic Poland syndrome deformity. Given the rarity of this syndrome, we recommend a treatment by an operator who makes the learning curve of lipomodeling, and who often deals with Poland syndrome.

[Management of breast asymmetry associated with primary funnel chest]. / Correction des asymétries mammaires associées au pectus excavatum primaire.

STUDY PURPOSE: The funnel chest or pectus excavatum (PE) is the most common congenital deformity. In women, it can be associated in some cases with breast asymmetry. It is the main cause of consultation in these patients. We report our management of this malformation by thoracic silicone prothesis modeled by computer-aided design. MATERIALS AND METHODS: Two correction procedures are proposed: One-stage procedure including thoracic silicone prothesis or breast implants only, or two-stage procedure by the combination of the two techniques in two steps. RESULTS: Between 1998 and 2011, 31 patients had a PE, within 26 patients were treated for breast asymmetry associated with a PE. The average age was 23.1 years (15-39). The median follow-up was 65 months (24-86). Type I Chin was found in five cases (19%), type II in two cases (7.7%) and type III Chin was found in 19 cases (73%). Of these 26 patients, in both cases a breast augmentation with asymmetric volumes of implants (7.7%) has adequately corrected the problem. Thoracic endoprothesis was performed in 24 patients to treat the initial breast asymmetry. Twenty-one patients (87.5%) were satisfied with the final symmetry and have not required a breast augmentation. Three patients (12.5%) underwent a second surgical procedure to correct the initial breast asymmetry. CONCLUSIONS: Breasts asymmetries associated with PE can be adequately corrected using an isolated thoracic endoprothesis. Whether it remains a lack of results, perform an unilaterally or bilaterally breast augmentation in a second time is always possible.

[Aesthetic gluteal region reconstruction with a perforator artery flap]. / Reconstruction fessière esthétique fiabilisée par une artère perforante glutéale.

The gluteal region is an important pressure zone in every day life. Defects associated with bone exposure in the sacral region are more frequent among pressure sores. The gold standard treatment consists in a musculocutaneous gluteal flap; it can have as side effects functional deficits for walking and an important scar. In order to diminish the donor site morbidity muscle sparing flaps, as perforator flaps, have been described. The purpose of this article is to report the case of a 29-year-old patient with a median sacral defect with bone exposure after oncological resection, covered by a perforator gluteal flap. A superior gluteal artery perforator was researched using a Doppler flowmetry. The role of the perforator was to make the flap more reliable and to obtain a higher degree of mobilization of the flap devoid of tension or flap morbidity, without interfering with the gluteus maximus muscle integrity. Also, the aesthetic units of the gluteal region have been considered in order to obtain a better scar quality. At the 4 months follow-up, the result was stable with a discrete scar and no walking difficulties. In conclusion, the median defects associating bone exposure in the sacral region are difficult to treat, especially in young patients. The treatment should consist in a stable soft tissue coverage with minimal functional and aesthetic sequela. The perforator gluteal flap respects the aesthetic units and can be considered as an elegant and efficient solution to treat this type of defects.